Clinical management and outcome of adult patients with extracorporeal life support device–associated intracerebral hemorrhage—a neurocritical perspective and grading

Abstract

Intracerebral hemorrhage (ICH) is a devastating complication in patients treated with extracorporeal membrane oxygenation (ECMO) due to respiratory or cardiac issues. Neurosurgical evaluation and management of such cases has only insufficiently been studied. We conducted a retrospective, cohort study of adult patients treated with ECMO between January 2007 and January 2017 in a tertiary healthcare center. Demographics, clinical data, coagulation status, ICH characteristics, and treatment modalities were analyzed. The primary outcome parameter was defined as mortality caused by ICH during ECMO. 525 patients with ECMO therapy were eligible for analysis. An overall incidence for any type of intracranial bleeding of 12.3% was found. Small hemorrhages accounted for 6.4% and acute subdural and epidural hematoma for 1.2%. Twenty-four (4.6%) patients developed ICH, and 11 patients (46%) died due to the ICH. Mortality was significantly higher in patients with larger ICH volumes (86.8 ± 34.8 ml vs 9.9 ± 20.3 ml, p < 0.001), intraventricular hemorrhage (83% vs 8%, p = 0.01), and a fluid level inside the ICH (75% vs 31%, p = 0.04). All patients were classified according to the bleeding pattern on the initial CT scan into 3 types. Patients with type 1 bleeding were statistically more likely to die (p < 0.001). In 15 out of 24 patients (63%), correction of the coagulation status was possible within 12 h after ICH onset. Seven out of 9 patients (78%) without early coagulation correction died compared to 2 out of 15 patients (13%), in whom early coagulation correction was successful (p = 0.01). This is the first study evaluating the course and management of patients experiencing an ICH under ECMO therapy and establishing an ICH classification based on the bleeding patterns. Early correction of the coagulation is of paramount importance in the treatment of these patients.

Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study

“…The main findings of our study are as follows: (1) Over 10 years, we found ICRH in 21% of ARDS patients who had a brain CT scan during vv-ECMO support. (2) The majority of intracranial bleeding events were categorized as grade I/A in our study population [ 6 ]. (3) ICRH occurred in 35.4% of patients with and 16.7% of patients without COVID-19-associated ARDS during vv-ECMO support.…”

“…ECMO has evolved as a promising technique in the management of ARDS refractory to mechanical ventilation and adjunctive treatment [ 3 , 15 ]. Intracranial bleeding events are among the most feared ECMO-related complications and are associated with unacceptably high mortality [ 5 , 6 , 10 ]. The reasons for poor outcomes in patients with intracranial complications are multifactorial.…”

“…In case of multiple bleeding spots, single volumes were summed up. The location, distribution, and extent of intraparenchymal hemorrhage were categorized according to the classification proposed by Prinz et al, and ECMO-associated bleeding events were categorized as lobar intraparenchymal hemorrhage with, I/A, or without IVH, II/B, and multiple small bleeding spots, III/C [ 6 ]. The classification has been linked with clinical outcome with type I/A hemorrhage resulting in poorest outcomes.…”

“…All ICRH occurred during the ICU stay. The median time between ICU admission and ICRH was 10 days (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18), and the median time between ECMO initiation and ICRH was 7 days (3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Regarding the total number of patients who received vv-ECMO for acute respiratory failure throughout the study period, the incidence of ICRH is 10.7% (n = 43/402).…”

“…Similarly, ECMO should be considered in COVID-19-associated ARDS with hypoxemia or hypercapnia not responding to adjunctive treatment [ 2 , 4 ]. Although providing lifesaving pulmonary support, ECMO-related complications may be associated with fatal outcomes [ 5 , 6 , 7 ]. Studies of intracranial adverse events associated with ECMO therapy from the pre-COVID-19 era are manifold.…”